Factors affecting the manual linking of clinical progress notes to problems in daily clinical practice: A retrospective quantitative analysis and cross sectional survey.

This cross sectional study examines how patient characteristics, doctor characteristics, and doctors' education and attitudes affect the extent to which doctors link progress notes to clinical problems. The independent effects of patient characteristics on the linking of notes was examined with a mixed model logistic regression. The effects of doctor characteristics and doctors' education and attitudes on the link ratio was analyzed with univariate analysis of variance.

A hospital-wide transition from paper to digital problem-oriented clinical notes. A descriptive history and cross-sectional survey of use, usability, and satisfaction.

Objectives: To evaluate the use, usability, and physician satisfaction of a locally developed problem-oriented clinical notes application that replaced paper-based records in a large Dutch university medical center.

Methods: Using a clinical notes database and an application event log file and a cross-sectional survey of usability, authors retrospectively analyzed system usage for medical specialties, users, and patients over 4 years. A standardized questionnaire measured usability.

Does language ambiguity in clinical practice justify the introduction of standard terminology? An integrative review.

Aims And Objectives: To research the use of ambiguous language in written information concerning patients' functioning and to identify problems resulting from the use of ambiguous language in clinical practice.

Background: Many projects that aimed to introduce standard terminology concerning patients' functioning in clinical practice are unsuccessful because standard terminology is rarely used in clinical practice. These projects mainly aim to improve communication by reducing ambiguous language.

Modeling problem-oriented clinical notes.

Objectives: To develop a model as a starting-point for developing a problem-oriented clinical notes application as a generic component of an Electronic Health Record (EHR).

Methods: We used the generic conceptualization of Weed's problem-oriented medical record (POMR) to link progress notes to problems, and the Subjective, Objective, Assessment, Plan (SOAP) headings to classify elements of these notes. Health Level 7 (HL7) Version 3 and Unified Modeling Language (UML) were used for modeling.

Comparing patient characteristics, type of intervention, control, and outcome (PICO) queries with unguided searching: a randomized controlled crossover trial.

Background: Translating a question into a query using patient characteristics, type of intervention, control, and outcome (PICO) should help answer therapeutic questions in PubMed searches. The authors performed a randomized crossover trial to determine whether the PICO format was useful for quick searches of PubMed.

Methods: Twenty-two residents and specialists working at the Radboud University Nijmegen Medical Centre were trained in formulating PICO queries and then presented with a randomized set of questions derived from Cochrane reviews.